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Wednesday, February 22, 2012

Lying to patients: Part I of a two-part series

A survey just published in Health Affairs found that 20% of the nearly 2000 physician respondents said that “they had not fully disclosed mistakes to patients for fear of being sued” in the past year. When I first heard about this the other day, I tweeted the following, “And 80% lied.”

Now that I’ve had a chance to think about it, I still feel that way. Is it possible that 80% of the surveyed doctors did not make a single mistake over the course of a year? I would guess that many doctors who practice full time would have been likely to have made more than one error that led to significant harm to a patient. Do you think 80% of them owned up to it to the patient or his family?

I don’t think so. As much as it would be nice to live in an ideal world, we don’t. Despite research and assurances to the contrary, most doctors I know are not ready to confess their sins to patients because they do fear lawsuits. And that fear is well-founded. But it is unfortunate because in my limited experience [hard as it is to believe, I’ve made my share of mistakes], patients and families generally do take it well when you admit that you made a mistake and more importantly, say you are sorry.

One bright spot. I’m not surprised at this. The paper said, “General surgeons and pediatricians were most likely to completely agree about needing to disclose all serious medical errors to patients, while cardiologists and psychiatrists were least likely to report this attitude (p < 0:001).”

Having read the entire Health Affairs paper, which is entitled “Survey Shows That At Least Some Physicians Are Not Always Open or Honest with Patients,” I can point out another finding that did not receive enough attention. That is, 89% of physicians said that in the past year they never told a patient something that wasn’t true.

I am equally skeptical of that statement. Think about it. We have many opportunities to lie to patients. Many of them can at least be partially justified. In the so-called “informed consent” discussion, we don’t disclose every possible complication that has ever been associated with a procedure. If we did, no patient would ever consent to anything. What about injecting some local anesthesia and saying, “This won’t hurt. It’s just like a mosquito bite.” There are many more.

Many of the lies we tell patients are not intended to be malicious or deliberately deceiving, but they are still lies in the strict sense of the word. The bigger problem of disclosing errors in an honest and forthright way will happen more often when the punitive culture of medicine changes.

6 comments:

Anonymous
said...

I think it is a shame that we live in a society where people are almost looking for reasons to sue. They sue anyone for any harm that befalls them, no matter how little responsibility the other party has. Health issues are very emotional and can severely affect one's quality of life, making this area even more prone to lawsuits.

I have just a couple of comments about doctors lying to patients. I don't think it is very easy to tell which patients might sue you. That probably contributes to defensive medicine for ALL patients, as well as the incentive to lie.

Secondly, the gap between the medical knowledge of patients and that of doctors is increasing at a phenomenal rate. It is hard to get even college-educated patients to understand enough to know why doctors are making certain decisions. How much time can you spend explaining to someone who does not even have the basics of science in their skill set? I'm not sure how this relates to doctors lying; I think it contributes to patients suing, however. They simply did not understand why things happened the way they did, and if there is a negative outcome, they want to get money to compensate.

I would be curious to know in what other profession absolute perfection is required. I've never seen a computer programmer sued because of some program defect in software he wrote that resulted in harm to someone or their property. The company might be sued, but not the individual programmer. If doctors stopped working for themselves, maybe they could get a deal like that. Of course, most doctors don't want to answer to a boss. :)

Let me ask you a question, though. How do you think we should deal with truly incompetent doctors that are causing real harm or failing to help patients as they should be able to do? How can we deal with those doctors without creating an oppressive environment for the vast majority of doctors that do great work?

It gets even worse when you see states enacting "Wrongful Birth, Wrongful Life" legislation that allows doctors to lie to their patients if they think that information may lead the women in question to get an abortion. And then when a deformed or disabled baby is born they have no right to sue the doctor for lying to them or to sue for the cost of perpetual medical care.

I am struggling with some of the assertions made by the first anonymous commentator on February 23rd.

1.) Increasing knowledge gap between doctors & patients?

The internet is absolutely revolutionizing the doctor/patient relationship via informal education -- allowing patients to more thoughtfully participate in their treatment plans, especially in the area of "informed consent". If a patient wants to know all the bad things that could happen, the patient can now access that information without the doctors help. I would argue that it is more possible now for patients to not only understand - but to also recognize medical errors than ever before.

2.)Everyone is looking for a reason to sue? Doctors are supposed to be perfect?

I think these comments are simply uninformed. Doctors do make many mistakes -- like a wrong working diagnosis/wrong medication (ie: wrong spectrum antibiotic because of lag time between lab testing and disease management.) Most people understand these "mistakes" and accept them as reasonable risks in the course of being treated. Anyone attempting to sue for this kind of a "mistake" would be laughed out of court. We can't know everything all of the time. However, nobody in their right mind wants a surgeon with a poke & hope philosophy. The risks are just too high. But if you happen to be unlucky enough to be treated by one, I would argue that because we have the internet, it is easier for a lay person to recognize mistakes or variances from the standard of care than ever before. Is it that patients are sue happy, or that they just can say more definitively conclude that something was wrong with their treatment -- requiring justice in the form of compensation. (Right now this is about the only remedy for a patient when care goes awry).

3.) Doctors don't want a boss.

We are moving into a new era of conglomerate medicine. Large insurance companies contract with hospitals, and hospitals contract/hire doctors to fulfill insurance company requirements. This is especially seen in hospital affiliated primary care clinics, where doctors have given up private practice to become hospital employees. In my opinion, repeat malpracticing doctors are the ones being protected by the hospital employees & systems that employ/contract with them because hospitals can be found negligent for a doctors poor care choices. If a doctor is a mandatory reporter for serious medical errors (as in my state), they may still fail to report a serious error of a colleague for fear of hospital retaliation. This conflict of interest is a real fear -- doctors and nurses can be fired for "disruptive behavior" because the hospital want to protect their own skin, even if it means covering up bad mistakes and allowing poor practitioners to continue to work.

It seems to me that doctors are continually losing more professional power to act when they know someone is persistently injuring patients. How does medicine maintain it's status as a profession, when doctors do not feel able to report/sanction these bad apples? How do patients get justice -- including compensation for ongoing care needs after a serious mistake -- when the very people they are entrusting their lives to, feel unwilling/unable to act in the patient's best interest when care goes wrong?

Thank you for the well said comments, especially your third one. We all have bosses now whether we like it or not. I just saw the results of a survey that showed that 1% of graduating residents are planning to go into solo practice.